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CONSENSUS STATEMENT ON THE USE OF GADOLINIUM FOR MAGNETIC RESONANCE IMAGING USED IN THE DIAGNOSIS AND FOLLOW-UP OF PATIENTS WITH MULTIPLE SCLEROSIS
Jillian Katrina Chan1, Anthony Traboulsee2, Emanuel Kanal3, Kenneth Maravilla4, Lori Saslow5, Laura Barlow2, Bruce Cohen6, Kathleen Costello7, June Halper8, Colleen Harris9, David Jones10, Flavia Nelson11, Scott Newsome12, Jiwon Oh13, Daniel Pelletier14, Kottil Rammonhan15, Daniel Reich16, Alex Rovira17, Lael Stone18, Kevin Terashima16, Jerry Wolinsky11, and David Li2

1Neurology, University of British Columbia, Vancouver, BC, Canada, 2University of British Columbia, Vancouver, BC, Canada, 3University of Pittsburgh Medical Center, Pittsburgh, PA, United States, 4University of Washington, Seattle, WA, United States, 5LS Science and Medical Communications, LLC, Great Neck, NY, United States, 6Northwestern University Medical SChool, Chicago, IL, United States, 7Nathional MS Society, Maryland, MD, United States, 8Consortium of MS Centers, Hackensack, NJ, United States, 9University of Calgary, Calgary, AB, Canada, 10University of Virginia, Charlottesville, VA, United States, 11UT Health McGovern Medical School, Houston, TX, United States, 12Johns Hopkins Hospital, Baltimore, MD, United States, 13University of Toronto, Toronto, ON, Canada, 14Keck School of Medicine of USC, Los Angeles, CA, United States, 15University of Miami Multiple Sclerosis Center, Miami, FL, United States, 16Translational Neuroradiology Unit, NINDS, Bethesda, MD, United States, 17Section of Neuroradiology, Hospital Vall d'Hebron, Barcelona, Spain, 18Mellen Center for MS Treatment and Research, Cleveland, OH, United States

Synopsis

Clinical guidelines for the diagnosis and follow-up of multiple sclerosis recommends brain MR imaging with gadolinium based contrast agents. Our aim was to address concerns about the use of gadolinium, the risk of accumulation in the brain and propose changes to clinical guidelines published in 2016. Group consensus is that GBCA remain essential in the diagnostic evaluation of a patient suspected of having MS to demonstrate active inflammatory lesions. GBCA should be used judiciously, minimizing gadolinium exposure and dose when possible.

BACKGROUND

Clinical guidelines for the diagnosis and follow-up of multiple sclerosis1 recommends brain MR imaging with gadolinium based contrast agents (GBCA). Soon after publication of these recommendations, because of the issue of tissue deposition of gadolinium, a subsequent follow-up Letter to the Editor2 recommended the “judicious use of GBCA in certain circumstances, including early diagnosis of MS,” which was an important change compared to the earlier recommendation.

OBJECTIVES

To address concerns about the use of gadolinium, the risk of accumulation in the brain and propose changes to clinical guidelines1 published in 2016.

METHODS

The authors convened a consensus conference in early 2017. The meeting, sponsored by the Consortium of MS Centers, brought together an international group of neurologists, radiologists, and imaging scientists with an expertise in MS to revise and update the guidelines and indications for standardized brain and spinal cord MRI for MS including attention to the use of gadolinium, based on new data, survey results and expert opinion.

RESULTS

Recent literature3 has shown that all GBCA lead to retention of very small amounts of gadolinium (Gad) in the brain (predominantly dentate nuclei and globus pallidus), bone, skin, and elsewhere in the body, although different GBCA seem to retain Gad at different rates/amounts, with macrocyclic agents, in general, retaining less than linear agents. Consideration of GBCA and dose should depend on agent sensitivity to detect new inflammatory lesions as GBCA may vary in the degree to which they induce lesion enhancement per dose versus likelihood of tissue deposition. There have been no documented cases of clinical neuro-toxicity associated with Gad retention in the brain. Because health effects of Gad deposition in the brain are unknown, the need for contrast-enhanced studies must be clearly indicated.

CONCLUSION

Group consensus is that GBCA remain essential in the diagnostic evaluation of a patient suspected of having MS to demonstrate active inflammatory lesions. GBCA should be used judiciously, minimizing gadolinium exposure and dose when possible. Routine monitoring with GBCA may be useful in the following circumstances: suspicion of clinical disease activity for which confirmation may modify therapy, confirmation of lack of disease activity, and facilitating selection of disease modifying therapy.

Acknowledgements

No acknowledgement found.

References

1. Traboulsee A, Simon JH, Stone L, et al. Revised Recommendations of the Consortium of MS Centers Task Force for a Standardized MRI Protocol and Clinical Guidelines for the Diagnosis and Follow-Up of Multiple Sclerosis. AJNR Am J Neuroradiol. 2016;37(3):394-401. doi:10.3174/ajnr.A4539.

2. Traboulsee A, Li D. Addressing Concerns Regarding the Use of Gadolinium in a Standardized MRI Protocol for the Diagnosis and Follow-Up of Multiple Sclerosis. AJNR Am J Neuroradiol. 2016;37(12):E82-E83. doi:10.3174/ajnr.A4943.

3. Gulani V, Calamante F, Shellock FG, Kanal E, Reeder SB, International Society for Magnetic Resonance in Medicine. Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol. 2017;16(7):564-570.

Proc. Intl. Soc. Mag. Reson. Med. 26 (2018)
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